Provider Demographics
NPI:1629071451
Name:SHIN, YOON SUP (MD)
Entity Type:Individual
Prefix:DR
First Name:YOON
Middle Name:SUP
Last Name:SHIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:YOON
Other - Middle Name:SUP JAMES
Other - Last Name:SHIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2017 W OLYMPIC BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-3705
Mailing Address - Country:US
Mailing Address - Phone:213-480-1000
Mailing Address - Fax:213-401-0018
Practice Address - Street 1:2017 W OLYMPIC BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-3705
Practice Address - Country:US
Practice Address - Phone:213-480-1000
Practice Address - Fax:213-401-0018
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA85523207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA85523OtherLICENSE
BS8873449OtherDEA
I19374Medicare UPIN
WA85523AMedicare ID - Type Unspecified